Free Child Medical Consent

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Create Your Free Child Medical Consent

  1. Answer a few simple questions
  2. Email, download or print instantly
  3. Just takes 5 minutes

Child Medical Consent

Effective Date

Effective Date

When will this consent be valid?

The end date you have selected occurs before the start date.

Frequently Asked Questions
What is the start date?The start date is the date which the consent becomes effective and the temporary caregiver can begin to make medical decisions on behalf of the child.What is the end date?The end date is the date which the consent expires and the temporary caregiver will no longer have the power to make medical decisions on behalf of the child. If no end date is selected, the temporary caregiver will continue to have power indefinitely until the parent/guardian revokes it with a written notice to the proper parties.How do I end the authority of the temporary caregiver if I don't specify an end date?The parent/guardian may end the consent at any time by notifying the child's medical and insurance providers in writing that they wish to revoke the consent granted to the temporary caregiver.

Your Child Medical Consent

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  1. We, ____________________ and ____________________ of ________________________ make oath and say that we are the lawful guardians of the child listed below and there are no court orders now in effect that would prohibit us from conferring the power to consent upon another person.

    Information of Child

    ____________________, male, born 22 May 2019 at ________________________ and residing at ________________________

  2. We hereby authorise and appoint ____________________ of __________________________________________ as our agent. Our agent may consent to our child's
    1. transportation by ambulance;
    2. examination;
    3. x-rays;
    4. diagnoses;
    5. hospitalisation;
    6. anaesthesia;
    7. medication.

    We do not authorise ____________________ to consent to the transfusion of blood.

  3. Our agent may have access to any and all records, including, but not limited to, insurance records regarding any medical services or treatment provided.
  4. The purpose of this instrument is to give ____________________ the power and authority to consent to medical treatment for our child. This power and authority will be effective as of the 22nd day of May, 2019.
  5. We give this consent freely and knowingly in order to provide for the child and not as a result of coercion, duress or payments by any person or agency.
  6. This consent will remain in effect until it is revoked by notifying our child's medical, mental health care and insurance providers, in writing, and the agent named above that we wish to revoke it.
  7. Any questions or concerns regarding this authorisation may be directed to us at:

    Name: ____________________
    Address: ________________________
    Phone Number: ____________________
    Secondary Phone: ____________________
    Email: ____________________


Declared at (city) _______________________ on the ________ day of ________________, ________.

Before me, (Notary's name) _______________________________

Signature ____________________________________ (Seal)

Address ___________________________

Telephone __________________________

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